Popular Science Monthly/Volume 30/November 1886/The Hygienic Treatment of Consumption
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The Hygienic Treatment of Consumption
By Benjamin Ward Richardson
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By BENJAMIN WARD RICHARDSON, M.D., F.R.S.
THE progress of hygienic medicine in the last fifty years is the medical fact of the present age, and the fact that will stand out in boldest relief when the history of this period shall be written by some future Æsculapian scholar.
But, rapid and effective as this progress has been, the principles of hygiene are yet in their infancy. We have learned to appreciate the true value of hygienic principles in the prevention of diseases of the epidemic type; and the medical profession, throwing aside all selfish recollections, has been the first to teach the practice of these principles and to prove their force and vitality. The next step in the way of advancement is to demonstrate that the same principles are as useful and as necessary in the treatment of actual disease as they are in prevention.
A great advantage in the hygienic treatment of disease is, that it does not, or at least need not, interfere with sound and experience-proved modes of treatment of a medicinal kind. The scientific physician finds, in fact, that there is always a consistent plan for combining the medicinal and hygienic systems. He sees that the two systems are one; he sees further that the mere medicinal plan without the hygienic is in all cases imperfect, and in some cases worse then imperfect.
The practical details of hygienic medicine in relation to the treatment of disease have, however, yet to be wrought out more fully. This will be sure work, but slow. Necessarily slow, because it is hard to give up old friendships in dogmatism; while to effect a cure in a sick man by fresh air alone, or diet, is infinitely less satisfactory to the public than to assume to effect the same cure even by a bread-pill.
It is vain, it is sticking in the slough of hopelessness, to pander to these popular weaknesses; for though they must die out, and, indeed, are dying out daily, they will go the sooner if they are effectually damped, and if something real and common sense is put in their place. Scientiæ mutantur, et nos mutamur in illis. There is a time when medicines are invaluable; but, if faith in medicines is to be retained, the times for their administration, as well as their selection, must be learned by knowledge, not by routine, and must be dictated by the circumstances of the case, not by the caprice of the patient. The executive of medicine must be independent, if it would keep in the path of truth and advancement.
In such progress as has been made in the science of treatment by medicines, it has been found useful to take up certain particular diseases, and to observe in them, individually, the effects of particular remedies. This rule will apply with equal force in considering and 8o THE POPULAR SCIENCE MONTHLY.
investigating hygienic modes of treatment. Each practitioner should, as his opportunities permit, observe as carefully the effects of his hy- gienic commands as he does those of the medicines he may prescribe. He should compare also the one mode with the other, and calculate in each case their relative advantages. In this way he will have the opportunity of detecting with greater accuracy the pure effects of medicines themselves ; seeing that the action of medicines is greatly modified by the external conditions to which he who takes them is sub- jected.
Convinced of the importance of the above considerations, I have made it my business for thirty years past to mark out a series of hy- gienic rules for the treatment of consumptives ; and as I have had the best and widest opportunities of carrying out these rules in practice, and as the results have been satisfactory, I lay the views published, originally, while I was one of the physicians to the Royal Infirmary for Diseases of the Chest, once again, and briefly, before the public.
In giving the following rules, I presuppose their general applica- bility to cases of consumption in all stages of the disease : in the premonitory stage ; in the stage when the tubercular deposition is evident ; and in the next stage, when the local mischief is much fur- ther advanced. In the last stage even, though hope is lost, many of the rules may still be followed out with advantage, for by them the course of the disease is smoothed, and sometimes life is prolonged. In like manner, the rules are generally applicable to those who by hereditary taint are as yet but predisposed to the disease.
Rule I. A Sup2)l^/ of Pure Air for Respiration is the First Indi- cation in the Treatment of the Consumptive Patient. — In all cases of consumption, the attention of the physician should be at once directed to the quality of the air breathed by the patient.
In large cities, and even in small towns, it is next to impossible to get a constant supply of pure air in inhabited houses ; for houses are built according to false notions of comfort. " What a nice, cozy room ! " is a common expression applied innocently to every place where the greatest care has been taken to make an air-vault, without a " draught," and all ready for being charged with invisible impurities.
In a cozy i-oom the consumptive is bound never to live, nor, in- deed, in any one room for great lengths of time. So long as he is able to be out-of-doors, he is in his best and safest home. In the fields, on the hills, wherever the fresh air vivifies, where plants look most vigorous, and animals frisk about in the joy of health, there will the consumptive draw in his choicest medicine, there meet most advanta- geously the dangers of his disease, and there repair most easily the waste of tissue.
The inclemencies of the weather may temporarily, it is true, pre- vent the patient from his out-door existence. But even these inclemen- cies are not so much to be dreaded as confinement in a house. I have
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had occasion repeatedly to remark that if, from a few days' rain, the consumptives under my care "were confined to their homes, instead of being able to take the daily out-door breathing invariably prescribed under such circumstances, the aggravation of symptoms was always marked and universal. The appetite fell off, the debility became greater, the mind was less buoyant, the local mischief increased. The patients, too, previously accustomed to a full dose of the air-food, were not ignorant of the cause of these changes, for reduction in aii* is felt as quickly as reduction in common diet. Seeing these evils, then, I have long since thrown off the alarm about bad weather, and have or- dered every patient to seize, even in an inclement day, each gleam of sunshine, for the purpose of getting out for a breath of fresh air. The result of this practice has been most gratifying in all cases where the courage of the patient has admitted of its application.
Dr. Jackson, in speaking of out-door life, in much the same terms as the above, dwells very properly on the necessity of securing for this plan the confidence of the patient. The treatment " should not be done rashly, but boldly." If possible, "the patient should be made to have faith in it ; for without this he is not likely to pursue it as far as he can, and then he will not derive from it all the benefit which it can afford." This is the fact ; but the difficulty is at once got over if, under favorable conditions, the invalid can be induced to try the measure for a few days. Once tried, there is no fear, in the majority of cases, of its being given up, excejjt in instances where the disease is too far advanced, or where, from the poverty of the pa- tient, the pursuit of a sedentary occupation must needs be followed, even to the last days of existence. The benefit derived from this treatment is indeed so obvious, the debility is so much better borne, the relish for food is so much more markedly felt, the nights are passed with so much less of restlessness and cough, and with such an increase of sleep, that the sufferer soon instinctively feels the value of his instvuctions, and follows them out even more punctually than those which relate to the taking of medicines.
As much of the day, then, as is possible should be spent by the consumptive in the open air, and in places where the air is least im- peded and least corrupted. When he is compelled to keep the house, the necessary precautions must again be taken for procuring a free admission of the atmosphere. No cozy room with a temperature of 70°, with every crevice closed, and with an atmosphere in a dead calm and laden with impurities, should be permitted. But the temperature should be 60° Fahr. ; the fire, if there be one, should be in an open grate ; and by a free chimney-vent, secured by an Arnott valve, the freest possible current of air should be kept circiilating through the room. If the patient is cold, let him approach the fire, but let him not labor under the popular and fatal error that the way to obtain animal warmth is to shut out the air and roast the body. The heat
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of the body is made in the body itself, by virtue mainly of the oxygen supplied in the air ; and, as the body absorbs external heat with great difficulty, it would be as wise to attempt to give warmth by fires, hot bottles, and hot air, to a man who is not inhaling a due amount of oxygen, as to attempt the same process on a marble statue. In a word, external heat is useful only in preventing the too rapid radia- tion of animal heat from the surface of the animal body. Alone, it can not supply heat ; but, when a wholesome air is inspired, it can se- cure the retention of the heat that is developed in the animal furnace.
I spoke a moment ago of the open fire-grate. This is an essential for the room of the consumptive. Stoves of all kinds, heated pipes, and, in a word, all modes of supplying artificial warmth, except that by the radiation from an open fire, are, according to the facts which I have been able to collect, injurious. They are injurious because by their means the air is made too dry, an objection much less appli- cable to the open fire.
The symptom which I have most commonly seen elicited in the phthisical, by the inhalation of an unnaturally dry air, is haemoptysis, a symptom brought on frequently by the constant cough which the dry air excites. This effect, in a minor degree, will, in fact, appear in some cases without any actual deposition of tubercular matter, under the influence of the same cause.
The temperature of the air in the room of the consumptive should be carefully watched by the patient himself. My friend Mr. Glaisher, than whom no one is more competent to speak on this point, recom- mends two thermometers, the one with a wetted bulb. By the use of these the humidity, as well as the temperature, can be regulated. This is most advantageous, and the sensations of a consumptive patient soon inform him what degree of moisture is comfortable and proper.
I have occasionally heard phthisical patients complain of the use of gas in the rooms where they are confined. Such complaints, however, have usually come from patients confined in workshops where the num- ber of burners is very great, and where there is almost always some accidental escape of gas.
In private houses such objections are avoidable ; but as the inha- lation of coal-gas is injurious even in small quantities, and as the products of the combustion of the gas are also hurtful, the necessity of a free ventilation in rooms where it is burned, and in which con- sumptives are lodged, is the more urgent.
The care that should be taken to secure a good air in the living- rooms of the phthisical invalid must extend with equal care to the sleeping-apartment. This rule should always obtain when possible : never permit one room to perform the tico offices of bedroom, and living-room. The bedroom should be large, unencumbered by need- less furniture, and thoroughly ventilated. If the temperature of the air without is not below 60° Fahr., the windows of the room should be
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boldly set open, and be kept open at the top all night. If they are to be closed of necessity, a free chimney-draught must be procured, and an Arnott's valve is always an advantage. The bed should be free of curtains, but a single screen may be placed so as to ward off any direct draught from the door or window. Warmth of body is best secured by woolen bedclothes ; but, if the temperature of the air is below 60° Fahr.,' it will, with advantage, be raised to that pitch by a fire in the open grate. Gas should on no pretense be burned through the night in this bedroom, and as few other lights as possible, for the patient re- quires all the air that is to be had, and must not be carelessly robbed of it. Above all things, the consumptive person should be the sole occupant of his own bed and bedroom. To place such a one for sev- eral hours close to another person, however healthy, is injurious to both, but especially to the sick. No ties of relationship, and no mistaken kindness, should cause this rule of isolation ever to be broken.
It has been stated already that the room of the sufferer should be large. It should include, whenever practicable, at least fifteen hundred cubic feet of breathing-space, under all plans of ventilation. If more space can be had, all the better. If less only is obtainable, then the ventilation must be the more carefully attended to.
When the patient has left his room in the morning — and he should do so early — the windows and doors should be set open, and a current of air be allowed to flow through it during the whole of the day. If the air of the ajDartment be at a temperature below 60° Fahr., or loaded with moisture, the fire should be lighted two hours before bedtime.
Consumptive patients frequently ask, especially in winter-time, the value of what are called respirators ; and I have known some poor peo- ple purchase things of this description at what was to them consider- able cost. The use of mufflers, which are, in fact, respirators, has been known for ages ; and Dr. Hales, more than a century ago, recommended a scientifically made muffler for persons obliged to enter into places where noxious gases were given off. Dr. Beddoes, too, as Dr. Arnott shows, pointed out, in the year 1802, that a few folds of gauze held over the mouth and nose made the air warm and moist for respiration, and that such mufflers were, therefore, useful to consumptive and asthmatic persons. The object of the muffler or respirator is this : it retains the heat thrown out in the expired air, and gives up this heat to the cold air that enters in inspiration. In cold, dry weather, the muffler is very useful, and should be worn by all phthisical patients when out-of-doors ; but when the air is moist and cold it sometimes is complained of as embarrassing the respiration. It should then be thrown aside. Any patient may easily make one of these mufflers for himself, for the cost of a few pence, out of a piece of fine wire gauze, cut oval so as to cover the mouth and nose and fixed in the center of a small Shetland shawl, so that it may be tied on like an ordinary com- forter, with the gauze in the center for breathing through. The metal
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gauze, plated or silvered to prevent rust, "will last for several months, and in summer-time can be removed from the shawl and laid aside ; but the shawl is often useful in all seasons.
Rule II. Active Exercise is an JEssential Element in the Treatment of Co7isumptives. — The conditions for obtaining a due supply of air imply in some measure the necessity for exercise. But there are vari- eties of exercise. Drs. Rush, Jackson, and Parrish, are in favor of riding on horseback, but this is a thing not practically to be carried out in the majority of cases, and, as I think, not absolutely necessary. Walking is the more natural exercise ; it brings into movement every part of the body, more or less, and, leading to brisker circulation in every part, causes a more active nutrition generally. Of late years I have very much recommended tricycling to consumptive patients, and often with great benefit. In many instances it is better than walking exercise, giving more perfect change of air and scene with less fatigue.
The extent to which exercise should be carried will vary with the stage of the disease, and temporary accidents — such, for instance, as an attack of hiBmoptysis — may, for the moment, stop it altogether. But, when exercise is advisable, the general rule is to recommend that it be carried out systematically, cautiously, and courageously, and that each exercise should be continued until a gentle feeling of fatigue is felt through the whole muscular system. Violent and unequal exertion of the upper muscles of the body is unadvisable. When restored from the fatigue of one exercise, another should be undertaken, and during the day this can not be too often repeated. If the day be wet, then the exercise should be effected by walking in a large room, or by en- gaging in some game, such as skittles, billiards, or tennis.
If, in his waking hours, the consumptive patient can keep himself occupied pretty freely in muscular labor, he secures the best sudorific for his sleeping hours that can possibly be supplied ; for as the force of life is always expended in producing motion or action, so, to use the words of Dr. Metcalfe, " the proximate cause of sleep is an ex- penditure of the substance and vital energy of the brain, nerves, and voluntary muscles, beyond what they receive when awake ; and the specific office of sleep is the restoration of what has been wasted by exercise." Cough is very much less frequent in the course of the night in him who has been subjected to exercise in the day ; while sleep, when it falls, is more profound, more prolonged, and more re- freshing.
In summer-time, when the temperature of the day is high, the morning and the evening time are the best adapted for the periods of out-door exertion. In the other seasons, midday is preferable, as a general rule.
I have been asked, often, whether dancing is good exercise for children and young persons of a consumptive taint. There can be no doubt that it is so when properly conducted. When dancing is carried
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on, however, it must be done in a very large room, freely ventilated, and scrupulously free from dust ; for, the more exercise the body takes, the more air it requires, and the less of incumbrances in the way of mechanical obstacles to a free respiration. In damp days, when walk- ing out-of-doors is impossible, the consumptive child may thus have three hours' dancing with advantage ; not in stuck-up bowing and scraping, finnicking, polite quadrillism, but in good active dances, that make every limb feel pleasant fatigue.
In the performance of muscular exercise let the consumptive never encumber himself, nor check the free movements of his body, by strap- pings, loads of clothes, carrying of weights, and the like. These are but tasks ; they lead to unequal exertion in special sets of muscles, and to an inequality of expenditure of power which ought to be avoided.
A last consideration on the value of muscular exercise is, that it is eminently useful in keeping the respiratory muscles in a state of active nutrition. For, if to the loss of capaciousness in the lungs to receive air there is added a daily increasing failure in the muscles by which the acts of inspiration and expiration are carried on, it is clear that a double evil is at work. Now, this double evil is most actively pre- sented in consumption. As the respiratory muscles, together with the other muscles, lose their tone, so do the general symptoms of exhaus- tion increase in severity, sometimes without very marked change in the pathological condition of the lungs. In sequence, day by day, as the nutrition of these muscles decreases, and as they fail in tonic con- tractile power, they gain in excitability ; so that the irregular spas- modic contractions to which they are subjected in the act of coughing are produced by the merest excitement, and the cough is more frequent as it becomes more feeble.
Rule III. A Uniform Climate is an Important Element in the Treatment of Consumptives. — Consumptive patients are constantly asking questions as to the value of a change of climate. The poorest applicants for relief are anxious on this point, and are often ready at once to contemplate emigration, if the merest hope is given to them that such a course would prove beneficial. In considering climate, the fact should be remembered that the main point to be obtained is to se. lect such a part of the earth's surface as presents the nearest approach to an equality of temperature. Different writers of eminence have given the most contrary opinions on climate and consumption. Some have recommended a warm climate, others the polar regions. Both parties have spoken from experience, and they are, in some measure, both right ; for a climate equally cold and a climate equally hot are each much more favorable than one in which there are constant varia- tions, and where the thermometer in the course of the year ranges many degrees from freezing-point up to 100° Fahr. or higher. Speak- ing of 153,098 deaths from consumption occurring between the years 1841 and 1851, the Irish Census Commissioners observe :
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"As might naturally be expected, the seasons exercised a very marked influence upon the deaths from consumption. During the mild months of autumn, succeeding the warm season of summer, the deaths attributed to consumption amounted to only 23,010 ; with the cold of winter the mortality from this cause increased, so as to pre- sent a return of 38,956 ; but Avith the harsh, trying weather of spring it rose to 51,334, and in summer fell again to 39,798."
This statement represents a very important truth. It is certainly best for the patient if the temperature, while equal, be also temper- ate ; but a mean temperature of 35° on one side, or 75° on the other, is preferable to one varying constantly, to-day at 60° Fahr., to-mor- row at 40°, and a few days later at 80°.
From the experience gained in taking charge of a large number of consumptive patients it becomes a remarkable and highly-instruc- tive task to learn the influence of climatic changes on the symptoms of the disease. I can usually predict, almost with certainty, the his- tory I am to hear from the consumptives who are coming before me. If for some days there has been uniformity of temperature, and the weather has been mild and dry, so that an airing each day out-of- doors has been effected, the visit is quite a cheery one ; all seems bet- ter ; the medicines are said to agree. The cough is less troublesome, the body is warmer, and hope, diffusing an inward sunshine, lights up each face with brightness and activity. In frosty days, too, when the air is dry and the temperature continues even, the symptoms are often equally favorable ; but during periods, so common in this country in the spring and in the beginning of winter, when the atmospheric variations are sudden, marked, and often repeated in the course of a few weeks, the general aspect of affairs is widely different. I have heard on these occasions almost every patient complaining ; the symp- toms are all exaggerated, the mind discontented. There is a general request for a change in the medicine. Something is asked for that will soothe, for the nights are passed indifferently. It is useless to comply always with these demands, since the exaggerated train of complaints has a general and common cause ; but now and then the modification of symptoms is so great as to call for a modification of treatment. During these variations of season, deaths from consump- tion are most prevalent.
Thus an equable temperature is of great moment, and should al- ways be sought after by the phthisical sufferer. If he can not remove from his own locality, and if the variations in it are considerable, he must take the best precautions at his command. In-doors it is not difficult to sustain a pretty even temperature, varying from 55° to 60° Fahr. Out-of-doors, something must be done by attention to clothing, and by the use of the respirator. The most marked variations, how- ever, occur in the night, and hence the importance of keeping up an equality of warmth in the bedroom, in the manner already described.
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The reasons why consumptives feel the effects of climatic changes so much are sufficiently obvious. The effects of such variations are felt, indeed, in the best health ; for the body is in some measure both a barometer and a thermometer ; at all events, it is subject to the same influences, the lungs being in all cases the parts most affected. With the temperature moderately high and the air dry, the physiology of res- piration is carried on easily and well. The amount of oxygen taken in is ample ; the expiration of water, carbonic acid, and ammonia is free ; the pulmonic circuit of the blood is unimpeded ; the exhalation of water from the skin is unchecked ; and the radiation of heat from the body is moderate. Let these atmospheric conditions suddenly change for those in which the temperature is 35° Fahr., or less, and in which the air is charged with watery vapor, and the conditions of life are ma- terially modified. The supply of oxygen taken into the lungs is less ; the process of absorption of such oxygen by the blood is less ; the expired products are lessened ; the pulmonic circulation is impeded ; the watery exhalation from the skin is, in part, suppressed ; the radia- tion of heat from the body is much more rapid ; and, as a result of all, the whole man, body and mind, is enfeebled in force and in vitality. This is the course of things in a healthy man during atmospheric varia- tions. It is left with the reader to trace out the exaggerated evil of these changes in those who, at the most favorable times, are existing with the lungs reduced in capaciousness and the respiratory muscles in power.
I shall recommend no particular place as a resort for consumptives ; for I wish not to enter into disputation on this point. But here is the formula for an hypothetical Atlantis for consumptives : It should be near the sea-coast, and sheltered from easterly winds ; the soil should be dry ; the drinking-water pure ; the mean temperature about 60°, with a range of not more than ten or fifteen degrees on either side. It is not easy to fix any degree of humidity ; but extremes of dryness or of moisture are alike injurious. It is of importance in selecting a locality that the scenery should be enticing, so that the patient may be the more encouraged to spend his time out-of-doors in walking or riding exercise. A town where the residences are isolated and scat- tered about, and where drainage and cleanliness are attended to, is much preferable to one where the houses are closely packed, ho>vever small its population may be.
In speaking thus of the value of an equal climate, I am guided chiefly by the facts daily presented to me in relation to climatic varia- tions on patients living in these islands. Some aiithors, however, infer from mortality returns, gathered from various quarters of the world, that variations of climate do not materially affect the disease, but that it is uniformly more fatal in cities than in the country. In England the excess in cities is equal to twenty-five per cent.
The facts are not opposed to the value of climatic uniformity. On
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the contrary, they prove the vahie ; for as consumption is most rare in extreme northern climates, and at great elevations, so in these locali- ties are variations of climate less marked. It remains yet for statis- tics to show whether in the most favored patches of earth, where, with the absence of climatic variations, there is a genial but temperate warmth, the disease is less prominent and less fatal.
Rule IV. The Dress of the Conswvptive Patient should he adapted to equalize the Temperature of the Body, and so loose that it interferes in no icay with the Animal Functions. — Instinctive sensa- tions both in health and disease naturally dictate the above rule. But it is too commonly the fact that these sometimes are disobeyed. Some persons think it a hardy, and therefore a beneficial, plan to dress lightly in all weathers. Foolish mothers send out their children in mid-winter with bare legs and chests ; young ladies go to balls and evening parties with the upper part of their light dresses open over the throat and bosom. Others go on a different tack ; they must at all seasons be smothered up in flannels and outer dresses, layer upon layer, carrying with the severest fatigue as much weight of cloth as they possibly can. Such persons on both sides evidently misunder- stand the uses of clothes, or think them only ornamental appendages. Clothes are useful, in a sanitary point of view, simply as equalizers of temperature. Heat is transmitted slowly through flannel, so flannel is warm. For this reason, flannel which should be worn in winter is unnecessary in summer, unless it is of light and porous structure.
I speak here of the body in health. In the consumptive patient, the principle is modified. He, from the deficient play of his lungs, is virtually always living in winter ; and we may find him on the hottest days breathing with anxiety, and with his hands and feet and brow cold.
For the consumptive, therefore, flannel clothing is always required, and it should cover the whole of the body. The thickness of flannel must vary according to the sensations ; as far as is possible, the feel- ing of absolute cold ought to be at all times prevented. The con- sumptive should sleep also in flannel ; not in the dress worn during the day, but in a flannel gown. The shoes worn should be lined with flannel.
A common practice in the selection of clothes is to imagine that the weight of a garment conveys an idea of its warmth-sustaining power. This is an absurd error, and for consumptive persons this mistake about heavy clothing must be carefully avoided. They may safely trust to flannel of so porous a texture that it can be breathed through without offering any appreciable obstacle to the breath, and they may then walk out as warm as they can be made by clothing, without the risk of being wearied from the burden beyond their powers of endurance.
All absurdities in the way of hare-skins, warm plasters, and the
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like, placed specially on the chest, are useless ; and the plaster is worse than useless, since it checks the functions of the skin over a consider- able surface, and is soon dirty.
There is one modern article of attire on which a word of caution must be said, because its bad effects are unmistakable. I must warn all, but the consumptive in particular, against wearing what are called water-proof India-rubber coats. The healthy man may tolerate one of these garments ; the consumptive, never. It loads the under-clothes with moisture ; it gives a cold envelope to the surface ; it produces chill ; and, by checking the cutaneous function, it throws a double amount of work on lungs already failing under their ordinary duties.
Is it necessary to more than condemn those abominations of female attire, corsets ? I hope not. But not less injurious than the corset is the practice of placing a strap or belt round the waist, tightly buckled. In the old times, the ascetics wore the tight strap as a penance for sin. This was surely the true and original function of the article. Now it is a penance worn for society in a foolish mood.
Rule V. The Hours of Hest of the Consumptive Patient should he regulated mainly by the Absence of the Sun. — If exercise is impor- tant to the consumptive patient during the day, a due allowance of sleep is equally necessary during the night. The natural hours of sleep are from sunset to sunrise, and it is the business of the con- sumptive to make Nature his oracle. Shakespeare has happily said that sleep is the " chief nourisher of life's feast," and Menander held that it was " a remedy for every curable disease." The great use of sleep truly is to renovate ; for in the sleeping state the formative processes go on most actively. Metcalfe has well defined the differ- ence between exercise and sleep by saying that " during exercise the expenditure of the body exceeds the income ; whereas during sleep the income exceeds the expenditure."
It is obvious that to the consumptive person nothing can be more important than that the income should alternately and at natural sea- sons exceed the expenditure ; and it is quite remarkable how much alleviated all the symptoms of consumption are when sleep is insured. The rule I have laid down regarding the hours for sleep is imperative for many reasons : First, because in all seasons the actual amount of rest required by the natural man is pointed out by the course of the sun. Second, because to extend the day by artificial lights, making a little sun out of a gas-lamp or candle, is to feed that lamp with a part of the breathing store of the air, and vitiate the atmosphere. Third, because, though artificial light is injurious, the pure sunlight is, on the contrary, of the greatest worth in the acts of vitality.
Thus, to fulfill the natural law regulating the times of sleep, to escape from the artificial light, and to obtain the advantage of all the sunlight that can be secured, the consumptive patient should make the sun his fellow-workman.
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As soon as the patient has risen, he should at once leave his bed- room ; and, if the morning be fine, he should go into the open air. On this point Mr. Bodington, in a short essay " On the Treatment and Cure of Pulmonary Consumption," published in 1840, dwells with great force. " The profuse nocturnal perspirations are soon subdued," says Mr. Bodington, " by this method of treatment, and the debility they occasion avoided. The skin assumes a healthier action in proportion to the extent of exposure to the external atmosphere, particularly to the morning air."
In large towns the practicability of this last suggestion is less than in the country ; but, even in London life, an early morning walk should be made a matter of strict business by the consumptive. On a fine summer morning, between four and five o'clock, a walk through the streets and squares of London is, indeed, a treat which few London- ers understand. The air is free of smoke ; the thoroughfares are royal unimpeded highways ; and, while the great population sleeps, the mag- nitude of its residence is best seen and understood.
Rule VL The Occupation of the Consumptive Patient should he suspended if it is in-door or sedentary ; hut a certain Amount of Out- door Occupation may he advantayeous. — This rule is often difficult to carry out. At the same time it is second to none in importance, as there is, in a word, no exciting cause of consumption so general as in- door occupation. I remarked that about two out of every three pa- tients with consumption, who presented themselves before me at the Royal Infirmary, were employed in some in-door business. This was confirmed accurately by reference to the Infirmary books, the figures of which were very carefully analyzed for me by Mr. Pring, a student and assistant at the institution.
Out of five hundred and fifteen cases of consumption, not less thau 68'34 per cent, or rather more than two thirds, were persons follow- ing in-door occupations. Possibly the percentage was even higher, for all who called themselves laborers were presumed to be out-door work- ers. Among the in-door occupations which presented the largest num- ber of cases in this list, boot- and shoe-makers ranked first; needlewomen, second ; watch- and clock-makers, third ; domestic servants, fourth ; painters, fifth ; tailors, sixth ; printers, of whom the majority were com- positors, seventh ; bookbinders, eighth ; French polishers, ninth ; cigar- makers, tenth ; writers, eleventh ; smiths, twelfth ; tinmen, thirteenth ; and cabinet-makers, fourteenth. There were, altogether, in the list one hundred and forty trades specified, but the above-named fourteen yielded rather more than forty-four and a half per cent of the whole.
In the case of parents having children of a consumptive tendency, the greatest care should be taken to obtain for them out-door employ- ment. But here a serious delusion commonly comes into play. If the child is weakly, the anxious parent urges that it is unfit for hard labor and for out-door vicissitudes ; so it is sent to a place where it will not
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be exposed to cold or hard muscular work, like a draper's shop, or to some occupation of an in-door character. By this grand, ignorant, and fatal mistake, many victims are added to the list of the phthisical class of the community.
In many in-door occupations a double mischief is at work. The patient is not only confined in an impure air, but is made also to inhale some foreign agent, present of necessity from the character of his work, and with which the air is charged.
Some sedentary occupations beget a habit of muscular inactivity. Unworked machinery always resumes work lazily, and muscles long left to a passive nutrition respond slowly to the dictation of the will. The physical inertia conquers the mental powers. Hence some pa- tients can not be persuaded to give ujd their inactive pursuits, even when they have the opportunity. To j^rescribe to these individuals a walk of two miles a day is felt as a cruelty. Nor are these difficulties met with only in anaemic young girls, bleaching in millinery establish- ments, or in no establishments at all. They extend to men of various sorts : to men of letters, to men given up to sheer indolence, and to sedentary workmen, such as watch-makers, shoe-makers, and tailors.
On the other side, almost all occupations implying miuscular exer- tion out-of-doors, without undue exposure to wet and damp, may be pursued by the consumptive as long as possible, and with advantage. Work keeps the mind occupied and in healthful tune.
I remember a patient once who, in the first stage of consumption, insisted on coming into town each morning from a considerable dis- tance in the country, to look after his business, and to return home again in the afternoon. It mattered not that the sky looked threat- ening, for he was not afraid of such a trifle, although he thoroughly knew his critical condition. When expostulated with by his advisers (and, I am ashamed to say, by myself, for I was ignorant then of the truths I now state), his reply was : " My brothers and sisters have all died of consumption ; they were coddled up, nursed, carried about, confined to bed, and bound in the cords of helplessness by the kind- est hands, to the satisfaction of the doctor and of all concerned. But they soon died. I inherit the proclivity to the same disease, and I too shall die ; I know it ; but my course is different, for I have made up my mind to die in harness ; I have kept at my business in resistance to all entreaties, and I am the only one of the family left," The plan adopted by this man was right ; he bore the brunt of the disease for months, and is alive and occupied still.
I recommend all in whom consumption is hereditary, whose occu- pation is in the open air, to take to heart the motto of this man, to make up their minds " to die in harness." They will live the longer for the resolution.
At the same time, as there is a medium in all things, so is there in work and exercise. Excessive and violent muscular fatigue is next
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door in injuriousness to complete muscular inactivity ; and it is remarkable, in looking over tables of the occupations of consump- tives, to find that, among those who are reported to have been occu- pied in out-door work, the majority have belonged to pursuits which imply an extraordinary muscular expenditure.
Rule VII. Excessive Mental Exertion should he avoided by the Consumptive. — It is the fate of some members of the human family, who are of consumptive taint, to have minds of a very active and laborious character. As children, these love reading, and pursuits of an intellectual kind. They are specially precocious ; and admiring parents, with proud hopes as to the future of their offspring, encour- age an exertion which ought ever to be kept in bounds. As these precocities grow up, their mental development runs out of proportion to the development of the body. On this, muscular labor becomes a bore, and the study or desk the only enjoyable place in life. The result is, not that the mind by its overwork directly wears out the body, but that the body is neglected, and its physical degeneration hastened.
The bad effects show themselves first, according to my observa- tion, in derangement of the digestive system. In young persons of consumptive taint, the impaired nutrition of the whole body, incident to the impaired digestion and broken sleep, tells speedily on the res- piration, and supplies the first link in the fatal disease. Let all the absurd poetry about " those dying young whom the gods love " go its way. The gods love and help those who live naturally — and these die old.
I have seen so much mischief arise from tlie overwork of the mind, in consumptive children and youths, that I have dwelt no longer than is really necessary in treating on the importance of the present rule. If I had a child of decidedly consumptive tendency, he should scarcely touch books at all. He should be taught orally as much as possible ; he should be brought up in the open air, and to out-door sports and occupations ; and he should be encouraged to enter into every inno- cent game where the muscles are brought into vigorous play.
The choice of an occupation is best made by adopting the exclusion process. Exclude every calling in which close confinement to the study, the shop, the counting-house, or any other house, absorbs the greater part of life. The agricultural life is, on the whole, the best.
Every occupation will be modified with advantage by the enjoy- ment of ennobling pleasures. The dance, the lecture, the drama, mu- sic, is each good in its season, when attainable without injury to health. But from all crowded assemblies I warn the consumptive to keep away. The pleasure derived from them is nothing in compari- son to the evil insured in obtaining it.
Music has a grand influence on some minds, and may be cultivated with advantage under due regulations ; but upon wind-instruments
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the phthisical man should not exert his skill. The exertion of blow- inor these instruments interferes materially with the regular play of the respiration and circulation. In playing upon stringed instruments, moreover, the amusement should not be carried on until it wearies the performer. Mothers anxious for the accomplishments of their daughters make frequently a fatal mistake on this score. They place a poor child, who has no musical tastes, at the piano-forte ; and there she is made to sit hour after hour, until a lesson is perforce learned, or an exercise completed. ' The system, useless in an educational sense, is fraught with direct danger to health.
For the consumptive, reading aloud is a good daily practice. Cu- vier, the great naturalist, attributed his recovery from threatened phthisis to the delivery of some lectures which he was appointed to give. There should, of course, be a limit to the time of reading aloud ; it should never exceed an hour, should be stopped if hoarseness or weariness occur, and should be without effort or vociferation.
The selection of books for the entertainment of the mind is a fur- ther and important point. Exciting romances, filled with the narra- tions of deep and fiendish plots or hyper-poetic sentiments, are quite out of place, for they, through the mind, influence respiration to the detriment of the physical forces of life. So also do dull, monotonous, whining, terror-striking treatises, of whatever kind. But the book which is amusing, and which, with easy effort, raises the hearty laugh at an innocent picture, or the book which carries the reader along the page of history with gentle carriage, or tells of natural facts in natural language — this is the book to be sought for.
Singing is an amusement which may with prudence be followed by the consumptive in whom the tendency to the disease is indicated only, and the disease itself is not actually developed. The exertion must not, however, be kept up so long at any given time as to produce breathlessness or hoarseness. It must be done without labor or dis- tress, and at intervals when the body is in a condition to sustain the effort. It is then useful.
To sum up, the amusements of the consumptive should combine with the pleasure they afford a moderate and equal degree of muscular exercise, and with the muscular exercise a degree of exhilarating amuse- ment free from over-excitement and mental toil.
RiiLE YIII. Cleanliness of Body is a Special Point in the Treat- ment of Consumption. — But little need be said to enforce this rule. In health there is always a mutual understanding and a kind of part- nership between the skin and lungs. In consumption moderate action of the skin is a relief to the lungs, and as such ought to be encouraged. This is best attained by keeping the skin clean by daily ablution. Let the consumptive boldly take his bath as each morning comes ; not a shower-bath, not a cold bath, under any impression that water cast on the body in a certain fashion, or at a certain temperature, will give
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strength, but a tepid cleansing bath, with the temperature from five to ten degrees below that of the body. There is no occasion to stay in the bath a moment longer than to obtain a free ablution ; then the patient should rapidly but effectually dry himself all over with a rough towel, and dress with the flannel garment undermost.
The clothes of the patient should be scrupulously clean ; the under- clothing should be changed every day.
Rule IX. Abstinence from all Habits of Gross Sensual Indul- gence is an Essential Part both in the Prevention and the Cure of Consumptio7i. — I need not particularize the vicious sensual indul- gences to which many of human-kind habituate themselves ; for as sug- gestive descriptions are better left unwritten for those who are igno- rant of sensual indulgences, so for those who require to be forewarned no such descriptions are demanded, since they know too much already. In a word, I should say that, the grosser the sensuality indulged in, the greater is the physical evil resulting from it. Let the consump- tive, at least, bethink themselves what vices affect and prostrate most, and then with strong mind and will give them up altogether.
To those who have charge of the young, no duty is so imperative as that of carefully watching over the physical interests. Let these make it their first care to prevent the tendency to sensual debasement. In large schools, a little attention and firmness on the part of teachers and governors, with the assistance of medical supervision, would obvi- ate a host of life-long evils.
Rule X. The Diet of Co7isumptive Patients should he ample, and shoxdd contain a Larger Proportion of the Respnratory Constituents of Food than is required in Health. — The appetite of consumptive patients is very capricious, and daily grows more so if it be not sharpened up by exercise. When the food taken is not applied to the purposes of nutrition, it is better left untasted ; for otherwise it lies undigested in the alimentary canal, and sets up a serious train of dyspeptic symp- toms, nausea, and diarrhoea. Kind friends often, with the most pro- voking and mistaken good-nature, thrust upon the consumptive relays of the most improper food, because the necessity for nourishment is so obvious. But the fact is that, when the lungs are acting indiffer- ently, digestion can not go on actively, since, as Arbuthnot well ob- served, respiration is " the second digestion." Hence the quantity of food taken by the consumptive person should be small at each meal ; but the meals may, if the sensations of the patient require it, be more frequent than in health. Of animal foods, mutton is the best. Fatty and oily foods, which constitute the respiratory class, should predomi- nate, and fresh butter, with bread, may be taken almost ad libitum, so long as it agrees with the stomach. Cream, too, is excellent, and the luxury of curds and cream is very suitable. Milk, whenever it suits, is advisable as a constant drink-food, and good cows' milk, new, an- swers every purpose. There are, as far as I can gather from numerous
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cases in which I have seen them tried, no such specific virtues in asses' milk and goats' milk as some have supposed. Tea may be taken, in moderation, with perfect safety. Fresh vegetable diets should not be omitted ; and fruits, especially roasted apples, are always admissible, except in instances where they excite irregular action of the bowels. The Iceland moss has had a great reputation, as have jellies of differ- ent kinds, but these often are slow in digestion, and they have no sjjecific value.
The question of the use of alcohol in consumption is one on which scientific opinion is much divided. I have recommended alcohol under some conditions of the disease, and I have shown, on the other hand, that one particular kind of consumption may be produced by indul- gence in alcohol. Of late years I have prescribed alcohol very sparing- ly, and never in the form of the pernicious mixtures in which it is sold for general use under the names and forms of alcoholic beverages. When I now prescribe it, it is purely as a medicine and in the form of alcohol itself properly measured, properly diluted, and properly timed. In this form it comes under the head of medicinal, as distin- guished from hygienic, treatment, and, I am satisfied, with much more value than when it is inaccurately classified as a food or drink.
The two indulgences, snuff-taking and tobacco-smoking, ought to be strictly avoided by the consumptive.
Reviewing what has been thus written, I would add, as a supple- ment to the ten rules submitted, that, whenever distinct evidences of phthisis have set in in an individual of either sex, the marriage of such person is wrong, if not inexcusable ; while the marriage of two per- sons, both the victims of the disease, is opposed both to reason and humanity.
Concluding Note, — The above essay " On the Hygienic Treat- ment of Pulmonary Consumption " — less one or two minor revisions — was written and published under the same title in 1856.
The essay found little favor. It was considered as not practical, and as conveying the ideas of a dreamer, that the fatal disease, con- sumption, could be prevented generally, and treated specially by hy- gienic measures. To-day, under a revival of the old animalcular specu- lation as to the origin of some diseases from living forms — the entity doctrine in a new dress — the conception of the hygienic treatment of pulmonary consumption has been accepted in name as well as practice, as if it were new in word and in deed, the height of pi-actical learning and skill. So ideas change ; and the disfavored of one generation is the favored of another. But it matters not how or by whom it is borne, so long as the torchlight of truth makes its way. — The Asdejnod.